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Matching Clients’ Needs With Drug Treatment Services
Journal of Substance Abuse Treatment, Vol. 16, No. 4, pp. 299–305, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/99 $–see front matter
PII S0740-5472(98)00037-3
ARTICLE
Matching Clients’ Needs With Drug Treatment Services Yih-Ing Hser, phd,* Margaret L. Polinsky, phd,† Margaret Maglione, mpp,* and M. Douglas Anglin, phd* *UCLA Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles, CA †Center for Child and Family Policy Research, School of Public Policy and Social Research, University of California, Los Angeles, CA
Abstract – This paper reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in communitybased drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language). A 6-month follow-up interview reassessed clients’ problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation, and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention. © 1999 Elsevier Science Inc. All rights reserved. Keywords – matching; needs; treatment services.
INTRODUCTION
proach is effective for all clients with drug use problems, and that a range of alternatives is essential in order to suit individuals needs (Institute of Medicine, 1990). Therefore, optimum treatment involves the selection of the appropriate treatment or treatments most likely to facilitate a positive outcome in a particular individual—or effective matching. Client and treatment matching has long been an important research topic for its potential clinical significance and policy implications. Prior research efforts involving matching have concentrated mainly on matching clients to different settings or modalities and results have been discouraging (McLellan & Alterman, 1991). More promising matching efforts have been in terms of congruence between clients’ styles and therapeutic approaches (Nurco et al., 1988) and clients’ problems and treatment services (McLellan et al., 1996). Although many efforts have been devoted to examining client–treatment matching, overall, only a few studies have shown empirical ev-
Interest in matching clients to particular treatment has grown out of the recognition that drug problems vary in intensity, manifestation, and responsiveness to different treatment approaches (Finney & Moos, 1986; Hodgson, 1994; Institute of Medicine, 1990; Marlatt, 1988; McLellan & Alterman, 1991; Miller, 1989). Evaluation research has established that no single treatment ap-
This research was supported, in part, by research grants P50DA07699 and DA07382 from the National Institute on Drug Abuse (NIDA). Drs. Hser and Anglin are also supported by Research Scientist Development Awards (K02DA00139, K02DA00146, respectively) from NIDA. The authors are appreciative to Brian Chao and Brian Perrochet for their supportive work. Requests for reprints should be addressed to Yih-Ing Hser, PhD, UCLA Drug Abuse Research Center, 1100 Glendon Avenue, Suite 763, Los Angeles, CA 90024-3511. E-mail: [email protected]
Received April 14, 1997; Revised March 18, 1998; Accepted April 28, 1998.
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idence of more improvement in “matched” clients than those in various comparison groups (see Hser, 1995, or McLellan et al., 1996). In the real world of community-based programs, access to treatment is primarily predicated on cost and availability. Currently, public treatment systems in many communities have long waiting lists and a serious shortage of available slots. These constraints preclude implementation of matching practices that are insensitive to funding sources, availability of treatment slots, geographical convenience, and other logistic constraints (McLellan et al., 1996). In light of these considerations, we conducted a study to develop and test a viable matching procedure that would enable the use of all existing programs within a treatment network in the assignment of clients to the most appropriate options available, with the goals of increased efficiency for the system and improved benefit for the clients. We hypothesized that client outcomes would improve as a result of referral of clients to treatment programs offering specific services that matched the client’s expressed needs. The research protocol developed for matching clients to suitable treatment required the comprehensive assessment of client problem areas, identification of treatment programs with adequate service provision, and evaluation of treatment outcomes in terms of improvement in multiple areas. This paper reports the results of an initial attempt to provide an empirical basis for developing this approach, a nonexperimental study conducted to examine the potential utility of needs-and-services matching. AREAS OF PROBLEM/NEED Clients in drug treatment programs typically face multiple problems in addition to drug dependence. These other problem areas may include medical needs, psychological distress, legal involvement, employment problems, family relationship problems, and/or housing difficulties (McLellan et al., 1980). In addition to drug consumption, treatment efforts need to address these other problem areas that may be functionally related to drug use (Anglin & Hser, 1990). Evidence indicates that, if left untreated, these other life problems leave clients at high risk for relapse to drug use. In addition, clinical experiences indicate that barriers to participating or staying in treatment are often due to some day-to-day practical situations, such as the need for transportation or child care. Although drug treatment programs have increasingly recognized clients’ multiple needs and have increased service diversity to meet those needs, comprehensive programs providing services to meet all client needs are rare (Polinsky, Hser, Anglin, & Maglione, 1998). Treatment programs typically provide only basic types of services, occasionally supplemented with adjunct services that vary in intensity and duration. Even within the same program, clients may receive different mixtures of service types. Referral to treatment programs
that provide specific services needed by a particular client should optimize the chances that the client will receive the services that meet his or her needs. CLIENT PREFERENCES, PERCEPTIONS, AND PRACTICAL NEEDS Potential drug treatment clients often have specific ideas about the type of treatment or kinds of services they need. Studies have indicated that clients who were given a choice of treatment options showed greater acceptance of treatment and higher rates of recovery at follow-up (Kissin, Platz, & Su, 1971; Miller, 1985). On the other hand, many drug users may be in denial of their drug problem or factors contributing to their drug problem. Potential clients may not know the treatment program that can best attend to their problems. Nevertheless, to promote compliance and improve outcomes, client preferences must be taken into consideration when selecting a particular treatment program. Clients who do not obtain the services that meet their expressed needs are less likely to stay and benefit from treatment. THE PRESENT STUDY The present study assessed a sample of drug-using individuals who sought and were admitted to publicly funded treatment programs in Los Angeles County. The majority of these programs were outpatient drug-free programs. Clients were assessed prior to treatment entry and reassessed 6 months later to examine whether their needs had been met. The main purpose of the study was to investigate whether matching client needs and program services would improve treatment outcome, where client needs or desires for services were self-determined by client rating of the importance to have the treatment program provide such services. We also examined several related questions such as: What services were desired by the clients? Of those who expressed a desire for a particular service, how many received that service? Did clients who received their desired services do better than those who did not receive the services? METHODS Subjects The analysis included 171 subjects who participated in drug treatment programs after receiving a referral assessment. These subjects were recruited from two sources. One-hundred and forty-five subjects were recruited from a community resource center (CRC) that provided referrals to drug treatment programs in Los Angeles County. The CRC was supported by the Center for Substance Abuse Treatment (CSAT) Target Cities program to provide referral to local publicly funded treatment programs. The second source provided 26 subjects who
Needs and Services Matching
were participants in research projects conducted by the Drug Abuse Research Center at the University of California, Los Angeles. These projects were descriptive studies (not involving any intervention) designed to improve our understanding of the natural history of druguse patterns. Only subjects who were interested in receiving treatment referral and had subsequently entered a drug treatment program were included in the present study. This sample represented 62% of the total recruited 276 subjects (Hser, Maglione, Polinsky, & Anglin, 1997). The sample was approximately 48% female, 33% African American, 23% Hispanic or Latino, and 40% White. The mean age of the sample was 35 years (range 18–59) and the average years of education was 12. Major problem substances were: 32% cocaine/crack, 17% heroin/other opiates, 21% alcohol and other drugs, 8% polydrug without alcohol, and 22% other drugs, such as marijuana and PCP. Program modalities attended after referral were predominantly outpatient (80% drug-free, 2% methadone maintenance, 5% detoxification); 8% were residential and 4% were hospital inpatient. Fieldwork and Interview Procedures Subjects who gave their informed consent participated in two interviews 6 months apart. The initial assessment of the subject was conducted face-to-face and took about 45 minutes to complete. Clients were contacted 6 months later for a follow-up telephone interview, which took about 20 minutes.
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son was by that problem, and ratings of how important it was to get treatment or help for that problem. Ratings were on a 5-point scale, ranging from 0 5 not at all to 4 5 very much. For each of the eight domains, a severity score was derived ranging from 0 to 1; higher scores indicated worse severity (McLellan et al., 1992). Client preferences and opinions for treatment services were assessed at the initial interview by their ratings on the importance of receiving each of 30 specific services, including medical services, various types of counseling, vocational training, legal services, anger management, help in locating housing, transportation, practical skills training, child care, and so on (see examples in Table 1). At the follow-up interview, clients were asked if they had received any of the 30 services. We derived two measures to indicate the level of needs and services matching. One way to measure an overall matching index was to divide the total number of services received (of those desired) by the total number of services desired; ranging from 0 to 1. Another way was to calculate the total level of met versus unmet needs in the eight problem domains. For each domain, 0 5 no need, 21 5 need unmet, and 1 5 need met; the measure, which was the sum of these eight scores, ranged from 28 to 18. The preliminary analysis indicated that both measures yielded a similar pattern of relationships. To avoid multicollinearity, only the first measure was included in the multiple regression analysis.
RESULTS MEASURES The initial assessment instrument collected information on sociodemographic background (age, gender, ethnicity, education, and marital history); problem severity in multiple domains (alcohol use, drug use, medical status, employment, legal, family/social relationships, psychological, housing); current practical circumstances (legal status, financial resources, living arrangement); knowledge and preferences about drug use; previous treatment experiences; and preferred treatment services (e.g., transportation, child care needs). Most items for the measures of problem severity were taken from the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et al., 1992). The follow-up interview assessed changes in all problem areas assessed at the initial interview and the services received in the program. Eight ASI scores were calculated at both initial and follow-up interviews. Five domains (alcohol use, drug use, medical, psychological, and legal) were based on the original ASI items; two domains (employment, family/ social relationship) were based on modified items; and one domain (housing) was based on newly created items. The primary emphases of the questions (as in the original ASI) were on the number of days a problem was experienced in the past month, ratings of how troubled the per-
Needs for Services and Services Received Information about services desired by clients and services actually received is presented in Table 1. Overall, the most frequently reported services that were needed (besides counseling) were job training (116/171 5 68% of the overall sample), transportation (116/171 5 68%), housing (108/171 5 63%), and medical services (107/ 171 5 62%). However, the number of clients receiving each specific service was generally much lower than those expressing a need for that service. The percentage of time “service received” matched “service desired” reflects the degree of met or unmet need, as indicated in Table 1. Overall, unmet needs were extensive. Notably, of the services most clients needed, 53% of the transportation needs and 44% of medical services needs were met by programs. Only 10% of clients’ job training needs and 10% of housing needs were met. Treatment Retention To answer the question of whether matching client needs to program services improves treatment duration, we compared the number of days in treatment among three groups: those whose needs were met for a specific service (Needs Matched), those whose needs were unmet
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Y.-I. Hser et al. TABLE 1 Services Desired and Received in Drug Treatment Program (N 5 171)
Service
Medical General medical services Pregnancy Medication allowed HIV-related HIV testing AIDS counseling Counseling/self-help Individual counseling Group counseling Family/couples counseling 12-step groups Vocational Tutoring Job training Practical skills Communication training Anger management Money management Housing Locate housing Transportation Legal Legal assistance Social Social outings Cultural Religious emphasis Cultural/ethnic emphasis Family Services for children Children allowed at treatment Parenting skills training
Service Desired (n )
Service Received (n)
Received Service Desired (%)
107 28 90
47 3 18
43.9 10.7 20.0
85 53
31 25
49.7 47.2
131 102 87 107
114 81 17 46
87.0 79.4 19.5 43.0
63 116
5 12
7.9 10.3
99 76 90
14 25 11
14.1 32.9 12.2
108 116
11 62
10.2 53.4
84
9
10.7
84
18
21.4
64 30
25 13
39.1 43.3
65 51 65
14 18 32
21.5 35.3 49.2
(Needs Unmatched), and those who expressed no need for that specific service (No Needs). The analysis of variance (ANOVA) test results, shown in Table 2, suggested that matching certain types of services to needs (vocational services, child care, housing, and transportation) seemed to improve retention. Meeting needs for legal assistance, medical services, family counseling, cultural/ ethnic sensitivity, and parenting skills did not significantly improve retention. We examined predictors of treatment retention for the overall sample. The two measures of needs-and-servicesmatching were both significantly correlated with treatment retention. We then conducted a multiple regression analysis using treatment retention as the dependent variable. As mentioned earlier, we included one matching index in the regression analysis to avoid multicollinearity. The predictors also included demographics (gender, race/ethnicity, age), drug use severity at intake, and unmet needs in several areas (including vocational, child care, transportation, housing). Only older age, less drug use severity at initial assessment, and a higher matching
index significantly predicated longer treatment retention (Table 3). Thus, the study results supported the hypothesis that when client needs are better met by program services, treatment retention is improved. Improvement in Problem Severity ASI severity scores at baseline and follow-up in each specific area were compared for subjects who received a desired service (Needs Matched) or did not (Needs Unmatched), and subjects who did not request that service (No Needs). Except for legal assistance, those who received needed services in a particular problem area (Needs Matched) showed improvement in that area, compared to those who did not receive services to meet their specific needs (Needs Unmatched). For example, clients who reported need for and received vocational training showed an aggregate 32% improvement in the employment problem severity score, while those whose needs were unmet showed 20% improvement, and those who expressed no needs for vocational services showed
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TABLE 2 Treatment Retention (N 5 171): Contrasts Among Needs Matched, Needs Unmatched, and No Needs for a Specific Service Type
Days in Treatment Needs/Services
Vocational services* Childcare* Housing services Parenting skills Transportation* Legal assistance Family counseling Medical services Cultural/ethnic emphasis
Needs Matched
Needs Unmatched
No Needs
164 (12) 156 (18) 151 (11) 121 (32) 118 (62) 117 (9) 106 (17) 94 (47) 92 (13)
99 (104) 104 (33) 103 (97) 96 (33) 81 (54) 110 (75) 94 (70) 115 (60) 98 (17)
104 (55) 98 (120) 100 (63) 103 (106) 114 (55) 100 (87) 114 (84) 104 (64) 107 (141)
Numbers in parentheses represents the number of subjects in that category. *p , .05.
14% improvement. Clients’ housing problem severity scores showed 70% improvement among those who received housing services, 37% among those who did not receive housing services, and 25% among those who reported no housing needs. The positive impact with respect to vocational training services and housing services are highlighted in Figure 1. Improvements in some problem areas appeared to be associated with parallel reduction in drug use problems. For example, there was a 50% reduction in drug use severity score among those who received help with locating housing, a 23% reduction among those who did not receive help with locating housing, and a 41% reduction among those who did not declare a need for housing services. Similar improvement was observed among those who had children. For those who requested and received the service of having their children allowed at programs
TABLE 3 Multiple Regression Predicting Treatment Retention
Male Race/ethnicity Black Latino Other Age Severity of drug use Matching index Adjusted R 2
Standardized b
p
2.08
.255
2.14 2.05 2.10 .18 2.34 .16 .16
.092 .503 .171 .016 .000 .023
(Needs Matched), there was a 45% reduction in drug use severity score, while there was 20% reduction in the group that requested but did not receive the service (Needs Unmatched) and a 31% reduction in the group that did not request the service (No Needs). However, parallel improvement in a problem area and improvement in drug use severity score was not observed in problem areas other than those related to housing and child care. Retention and Posttreatment Drug Use Severity A positive correlation (r 5 .11) was found between treatment retention and improvement in drug use severity score, but it was not statistically significant (p 5 .16). Although nonsignificant, the relationship between retention and reduction in drug use was consistent with most prior studies that demonstrated positive relationships between treatment retention and favorable treatment outcome (DeLeon, 1991; Hubbard et al., 1989; Simpson, 1979, 1981). DISCUSSION The primary issue addressed in our study was whether matching client needs and program services improved client treatment outcomes, and our study results suggested that matching needs and services does matter for clients who receive requested services. The types of desired services ranged from those seven areas assessed by the ASI and housing services to those often considered
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FIGURE 1. Improvement in housing, vocation, and drug use severity: Contrasts among needs matched, unmatched, and no needs.
“wrap around” services, such as transportation and child care. Clients who received the desired services stayed in treatment significantly longer and showed more improvement in the corresponding problem area than those who did not receive the desired services. Similar patterns of improvement in drug use severity were observed in association with improvement in certain problem areas. The overall matching index also provided encouraging findings. Clients with a higher level of matching in needs and services stayed in treatment longer. Furthermore, while the benefit of matching was dramatic in many service and need areas, it should be noted that the percent of clients in the “Needs Matched” group was much smaller than that in the “Needs Unmatched” group (except for transportation). As a matter of fact, besides some general counseling, the proportion of clients who received specific services was generally low and most of their reported needs were not met in the treatment programs. This finding is similar to those reported by other studies (Etheridge, Craddock, Dunteman, Hubbard, 1995; Schottenfeld, Pascale, & Sokolowski, 1992). Given the current trend of diminished levels of funding, it is anticipated that types of services provided and planned treatment retention are likely to be further reduced in the future. The present study provides evidence that such reductions are likely to have a negative impact on client outcomes. The present study was nonexperimental. The measure of services received was limited only to the types of service asked about and gave no indication of intensity or frequency. However, the findings are consistent with other experimental and nonexperimental studies (Hoff-
man et al., 1994; McLellan, Arndt, Metzger, Woody, & O’Brien, 1993) that demonstrated that enhancing treatment services provided to clients is an important means of increasing client retention and improving treatment outcomes. The unique aspect of the present study was that client preferences and opinions were considered in measuring need for services and the potential impact of matching. Clients themselves were explicitly asked if a specific type of service was important for them to receive in their drug treatment program. The positive findings associated with client-determined needs for services suggest that clients are an important source for identifying needs and designing treatment plans and service provision. REFERENCES Anglin, M.D., & Hser, Y. (1990). Treatment of drug abuse. In M. Tonry & J.Q. Wilson (Eds.), Crime and justice: An annual review of research (Vol. 13, pp. 393–460). Chicago: University of Chicago Press. DeLeon, G. (1991). Retention in drug-free therapeutic communities. NIDA Research Monograph, 106, 218–244. Etheridge, R.M., Craddock, S.G., Dunteman, G.H., & Hubbard, R.L. (1995). Treatment services in two national studies of communitybased drug abuse treatment programs. Journal of Substance Abuse, 7, 9–26. Finney, J.W., & Moos, R.H. (1986). Matching patients with treatments: Conceptual and methodological issues. Journal of Studies on Alcohol, 47, 122–134. Hodgson, R. (1994). Treatment of alcohol problems. Addiction, 89, 1529–1534. Hoffman, J.A., Caudill, B.D., Koman, J.J., III, Luckey, J.W., Flynn, P.M., & Hubbard, R.L. (1994). Comparative cocaine abuse treatment strategies: Enhancing client retention and treatment exposure. Journal of Addictive Diseases, 13, 115–128. Hser, Y. (1995). A referral system that matches drug users to treatment
Needs and Services Matching programs: Existing research and relevant issues. Journal of Drug Issues, 25, 153–168. Hser, Y., Maglione, M., Polinsky, M.L., & Anglin, M.D. (1997). Predicting drug treatment entry among treatment-seeking individuals. Journal of Substance Abuse Treatment, 15, 213–220. Hubbard, R.L., Marsden, M.E., Rachal, J.V., Harwood, H.J., Cavanaugh, E.R., & Ginzburg, H.M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC: University of North Carolina Press. Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press. Kissin, B., Platz, A., & Su, W.H. (1971). Selective factors in treatment choice and outcome alcoholics. In N.K. Mello and J.K. Mendelson (Eds.), Recent advances in studies of alcoholism (NIMH Publication No. [HSM] 71-9045, pp. 781–802). Washington, DC: U.S. Government Printing Office. Marlatt, G.A. (1988). Matching clients to treatment: Treatment models and stages of change. In D.M. Donovan & G.A. Marlatt (Eds.), Assessment of addictive behaviors: The Guilford behavioral assessment series (pp. 474–483). New York: Guilford Press. McLellan, A.T., & Alterman, A.I. (1991). Patient treatment matching: A conceptual and methodological review with suggestions for future research. NIDA Research Monograph, 106, 114–135. McLellan, A.T., Arndt, I.O., Metzger, D.S., Woody, G.E., & O’Brien, C.P. (1993). The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association, 269, 1953–1959. McLellan, A.T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grisson, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199–213.
305 McLellan, A.T., Luborsky, L., Woody, G.E., & O’Brien, C.P. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease, 168, 26–33. McLellan, A.T., Woody, G.E., Metzger, D., McKay, J., Durrell, J., Alterman, A.I., & O’Brien, C.P. (1996). Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons. Milbank Quarterly, 74, 51–85. Miller, W.R. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98, 84–107. Miller, W.R. (1989). Matching individuals with interventions. In R.K. Hester & W.R. Miller (Eds.), Pergamon General Psychology Series: Vol. 157. Handbook of alcoholism treatment approaches: Effective alternatives (pp. 261–271). Elmsford, NY: Pergamon Press, Inc. Nurco, D.N., Shaffer, J.W., Hanlon, T.E., Kinlock, T.W., Duszynski, K.R., & Stephenson, P. (1988). Relationships between client/counselor congruence and treatment outcome among narcotic addicts. Comprehensive Psychiatry, 29, 48–54. Polinsky, M.L., Hser, Y., Anglin, M.D., & Maglione, M.A. (1998). Drug-user treatment programs in a large metropolitan area. Substance Use and Misuse, 33, 1739–1765. Schottenfeld, R.S., Pascale, R., & Sokolowski, S. (1992). Matching services to needs: Vocational services for substance abusers. Journal of Substance Abuse Treatment, 9, 3–8. Simpson, D.D. (1979). The relation of time spent in drug abuse treatment to posttreatment outcome. American Journal of Psychiatry, 136, 1449–1453. Simpson, D.D. (1981). Treatment for drug abuse: Follow-up outcomes and length of time spent. Archives of General Psychiatry, 38, 875–880.
PII S0740-5472(98)00037-3
ARTICLE
Matching Clients’ Needs With Drug Treatment Services Yih-Ing Hser, phd,* Margaret L. Polinsky, phd,† Margaret Maglione, mpp,* and M. Douglas Anglin, phd* *UCLA Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles, CA †Center for Child and Family Policy Research, School of Public Policy and Social Research, University of California, Los Angeles, CA
Abstract – This paper reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in communitybased drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language). A 6-month follow-up interview reassessed clients’ problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation, and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention. © 1999 Elsevier Science Inc. All rights reserved. Keywords – matching; needs; treatment services.
INTRODUCTION
proach is effective for all clients with drug use problems, and that a range of alternatives is essential in order to suit individuals needs (Institute of Medicine, 1990). Therefore, optimum treatment involves the selection of the appropriate treatment or treatments most likely to facilitate a positive outcome in a particular individual—or effective matching. Client and treatment matching has long been an important research topic for its potential clinical significance and policy implications. Prior research efforts involving matching have concentrated mainly on matching clients to different settings or modalities and results have been discouraging (McLellan & Alterman, 1991). More promising matching efforts have been in terms of congruence between clients’ styles and therapeutic approaches (Nurco et al., 1988) and clients’ problems and treatment services (McLellan et al., 1996). Although many efforts have been devoted to examining client–treatment matching, overall, only a few studies have shown empirical ev-
Interest in matching clients to particular treatment has grown out of the recognition that drug problems vary in intensity, manifestation, and responsiveness to different treatment approaches (Finney & Moos, 1986; Hodgson, 1994; Institute of Medicine, 1990; Marlatt, 1988; McLellan & Alterman, 1991; Miller, 1989). Evaluation research has established that no single treatment ap-
This research was supported, in part, by research grants P50DA07699 and DA07382 from the National Institute on Drug Abuse (NIDA). Drs. Hser and Anglin are also supported by Research Scientist Development Awards (K02DA00139, K02DA00146, respectively) from NIDA. The authors are appreciative to Brian Chao and Brian Perrochet for their supportive work. Requests for reprints should be addressed to Yih-Ing Hser, PhD, UCLA Drug Abuse Research Center, 1100 Glendon Avenue, Suite 763, Los Angeles, CA 90024-3511. E-mail: [email protected]
Received April 14, 1997; Revised March 18, 1998; Accepted April 28, 1998.
299
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Y.-I. Hser et al.
idence of more improvement in “matched” clients than those in various comparison groups (see Hser, 1995, or McLellan et al., 1996). In the real world of community-based programs, access to treatment is primarily predicated on cost and availability. Currently, public treatment systems in many communities have long waiting lists and a serious shortage of available slots. These constraints preclude implementation of matching practices that are insensitive to funding sources, availability of treatment slots, geographical convenience, and other logistic constraints (McLellan et al., 1996). In light of these considerations, we conducted a study to develop and test a viable matching procedure that would enable the use of all existing programs within a treatment network in the assignment of clients to the most appropriate options available, with the goals of increased efficiency for the system and improved benefit for the clients. We hypothesized that client outcomes would improve as a result of referral of clients to treatment programs offering specific services that matched the client’s expressed needs. The research protocol developed for matching clients to suitable treatment required the comprehensive assessment of client problem areas, identification of treatment programs with adequate service provision, and evaluation of treatment outcomes in terms of improvement in multiple areas. This paper reports the results of an initial attempt to provide an empirical basis for developing this approach, a nonexperimental study conducted to examine the potential utility of needs-and-services matching. AREAS OF PROBLEM/NEED Clients in drug treatment programs typically face multiple problems in addition to drug dependence. These other problem areas may include medical needs, psychological distress, legal involvement, employment problems, family relationship problems, and/or housing difficulties (McLellan et al., 1980). In addition to drug consumption, treatment efforts need to address these other problem areas that may be functionally related to drug use (Anglin & Hser, 1990). Evidence indicates that, if left untreated, these other life problems leave clients at high risk for relapse to drug use. In addition, clinical experiences indicate that barriers to participating or staying in treatment are often due to some day-to-day practical situations, such as the need for transportation or child care. Although drug treatment programs have increasingly recognized clients’ multiple needs and have increased service diversity to meet those needs, comprehensive programs providing services to meet all client needs are rare (Polinsky, Hser, Anglin, & Maglione, 1998). Treatment programs typically provide only basic types of services, occasionally supplemented with adjunct services that vary in intensity and duration. Even within the same program, clients may receive different mixtures of service types. Referral to treatment programs
that provide specific services needed by a particular client should optimize the chances that the client will receive the services that meet his or her needs. CLIENT PREFERENCES, PERCEPTIONS, AND PRACTICAL NEEDS Potential drug treatment clients often have specific ideas about the type of treatment or kinds of services they need. Studies have indicated that clients who were given a choice of treatment options showed greater acceptance of treatment and higher rates of recovery at follow-up (Kissin, Platz, & Su, 1971; Miller, 1985). On the other hand, many drug users may be in denial of their drug problem or factors contributing to their drug problem. Potential clients may not know the treatment program that can best attend to their problems. Nevertheless, to promote compliance and improve outcomes, client preferences must be taken into consideration when selecting a particular treatment program. Clients who do not obtain the services that meet their expressed needs are less likely to stay and benefit from treatment. THE PRESENT STUDY The present study assessed a sample of drug-using individuals who sought and were admitted to publicly funded treatment programs in Los Angeles County. The majority of these programs were outpatient drug-free programs. Clients were assessed prior to treatment entry and reassessed 6 months later to examine whether their needs had been met. The main purpose of the study was to investigate whether matching client needs and program services would improve treatment outcome, where client needs or desires for services were self-determined by client rating of the importance to have the treatment program provide such services. We also examined several related questions such as: What services were desired by the clients? Of those who expressed a desire for a particular service, how many received that service? Did clients who received their desired services do better than those who did not receive the services? METHODS Subjects The analysis included 171 subjects who participated in drug treatment programs after receiving a referral assessment. These subjects were recruited from two sources. One-hundred and forty-five subjects were recruited from a community resource center (CRC) that provided referrals to drug treatment programs in Los Angeles County. The CRC was supported by the Center for Substance Abuse Treatment (CSAT) Target Cities program to provide referral to local publicly funded treatment programs. The second source provided 26 subjects who
Needs and Services Matching
were participants in research projects conducted by the Drug Abuse Research Center at the University of California, Los Angeles. These projects were descriptive studies (not involving any intervention) designed to improve our understanding of the natural history of druguse patterns. Only subjects who were interested in receiving treatment referral and had subsequently entered a drug treatment program were included in the present study. This sample represented 62% of the total recruited 276 subjects (Hser, Maglione, Polinsky, & Anglin, 1997). The sample was approximately 48% female, 33% African American, 23% Hispanic or Latino, and 40% White. The mean age of the sample was 35 years (range 18–59) and the average years of education was 12. Major problem substances were: 32% cocaine/crack, 17% heroin/other opiates, 21% alcohol and other drugs, 8% polydrug without alcohol, and 22% other drugs, such as marijuana and PCP. Program modalities attended after referral were predominantly outpatient (80% drug-free, 2% methadone maintenance, 5% detoxification); 8% were residential and 4% were hospital inpatient. Fieldwork and Interview Procedures Subjects who gave their informed consent participated in two interviews 6 months apart. The initial assessment of the subject was conducted face-to-face and took about 45 minutes to complete. Clients were contacted 6 months later for a follow-up telephone interview, which took about 20 minutes.
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son was by that problem, and ratings of how important it was to get treatment or help for that problem. Ratings were on a 5-point scale, ranging from 0 5 not at all to 4 5 very much. For each of the eight domains, a severity score was derived ranging from 0 to 1; higher scores indicated worse severity (McLellan et al., 1992). Client preferences and opinions for treatment services were assessed at the initial interview by their ratings on the importance of receiving each of 30 specific services, including medical services, various types of counseling, vocational training, legal services, anger management, help in locating housing, transportation, practical skills training, child care, and so on (see examples in Table 1). At the follow-up interview, clients were asked if they had received any of the 30 services. We derived two measures to indicate the level of needs and services matching. One way to measure an overall matching index was to divide the total number of services received (of those desired) by the total number of services desired; ranging from 0 to 1. Another way was to calculate the total level of met versus unmet needs in the eight problem domains. For each domain, 0 5 no need, 21 5 need unmet, and 1 5 need met; the measure, which was the sum of these eight scores, ranged from 28 to 18. The preliminary analysis indicated that both measures yielded a similar pattern of relationships. To avoid multicollinearity, only the first measure was included in the multiple regression analysis.
RESULTS MEASURES The initial assessment instrument collected information on sociodemographic background (age, gender, ethnicity, education, and marital history); problem severity in multiple domains (alcohol use, drug use, medical status, employment, legal, family/social relationships, psychological, housing); current practical circumstances (legal status, financial resources, living arrangement); knowledge and preferences about drug use; previous treatment experiences; and preferred treatment services (e.g., transportation, child care needs). Most items for the measures of problem severity were taken from the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et al., 1992). The follow-up interview assessed changes in all problem areas assessed at the initial interview and the services received in the program. Eight ASI scores were calculated at both initial and follow-up interviews. Five domains (alcohol use, drug use, medical, psychological, and legal) were based on the original ASI items; two domains (employment, family/ social relationship) were based on modified items; and one domain (housing) was based on newly created items. The primary emphases of the questions (as in the original ASI) were on the number of days a problem was experienced in the past month, ratings of how troubled the per-
Needs for Services and Services Received Information about services desired by clients and services actually received is presented in Table 1. Overall, the most frequently reported services that were needed (besides counseling) were job training (116/171 5 68% of the overall sample), transportation (116/171 5 68%), housing (108/171 5 63%), and medical services (107/ 171 5 62%). However, the number of clients receiving each specific service was generally much lower than those expressing a need for that service. The percentage of time “service received” matched “service desired” reflects the degree of met or unmet need, as indicated in Table 1. Overall, unmet needs were extensive. Notably, of the services most clients needed, 53% of the transportation needs and 44% of medical services needs were met by programs. Only 10% of clients’ job training needs and 10% of housing needs were met. Treatment Retention To answer the question of whether matching client needs to program services improves treatment duration, we compared the number of days in treatment among three groups: those whose needs were met for a specific service (Needs Matched), those whose needs were unmet
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Y.-I. Hser et al. TABLE 1 Services Desired and Received in Drug Treatment Program (N 5 171)
Service
Medical General medical services Pregnancy Medication allowed HIV-related HIV testing AIDS counseling Counseling/self-help Individual counseling Group counseling Family/couples counseling 12-step groups Vocational Tutoring Job training Practical skills Communication training Anger management Money management Housing Locate housing Transportation Legal Legal assistance Social Social outings Cultural Religious emphasis Cultural/ethnic emphasis Family Services for children Children allowed at treatment Parenting skills training
Service Desired (n )
Service Received (n)
Received Service Desired (%)
107 28 90
47 3 18
43.9 10.7 20.0
85 53
31 25
49.7 47.2
131 102 87 107
114 81 17 46
87.0 79.4 19.5 43.0
63 116
5 12
7.9 10.3
99 76 90
14 25 11
14.1 32.9 12.2
108 116
11 62
10.2 53.4
84
9
10.7
84
18
21.4
64 30
25 13
39.1 43.3
65 51 65
14 18 32
21.5 35.3 49.2
(Needs Unmatched), and those who expressed no need for that specific service (No Needs). The analysis of variance (ANOVA) test results, shown in Table 2, suggested that matching certain types of services to needs (vocational services, child care, housing, and transportation) seemed to improve retention. Meeting needs for legal assistance, medical services, family counseling, cultural/ ethnic sensitivity, and parenting skills did not significantly improve retention. We examined predictors of treatment retention for the overall sample. The two measures of needs-and-servicesmatching were both significantly correlated with treatment retention. We then conducted a multiple regression analysis using treatment retention as the dependent variable. As mentioned earlier, we included one matching index in the regression analysis to avoid multicollinearity. The predictors also included demographics (gender, race/ethnicity, age), drug use severity at intake, and unmet needs in several areas (including vocational, child care, transportation, housing). Only older age, less drug use severity at initial assessment, and a higher matching
index significantly predicated longer treatment retention (Table 3). Thus, the study results supported the hypothesis that when client needs are better met by program services, treatment retention is improved. Improvement in Problem Severity ASI severity scores at baseline and follow-up in each specific area were compared for subjects who received a desired service (Needs Matched) or did not (Needs Unmatched), and subjects who did not request that service (No Needs). Except for legal assistance, those who received needed services in a particular problem area (Needs Matched) showed improvement in that area, compared to those who did not receive services to meet their specific needs (Needs Unmatched). For example, clients who reported need for and received vocational training showed an aggregate 32% improvement in the employment problem severity score, while those whose needs were unmet showed 20% improvement, and those who expressed no needs for vocational services showed
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TABLE 2 Treatment Retention (N 5 171): Contrasts Among Needs Matched, Needs Unmatched, and No Needs for a Specific Service Type
Days in Treatment Needs/Services
Vocational services* Childcare* Housing services Parenting skills Transportation* Legal assistance Family counseling Medical services Cultural/ethnic emphasis
Needs Matched
Needs Unmatched
No Needs
164 (12) 156 (18) 151 (11) 121 (32) 118 (62) 117 (9) 106 (17) 94 (47) 92 (13)
99 (104) 104 (33) 103 (97) 96 (33) 81 (54) 110 (75) 94 (70) 115 (60) 98 (17)
104 (55) 98 (120) 100 (63) 103 (106) 114 (55) 100 (87) 114 (84) 104 (64) 107 (141)
Numbers in parentheses represents the number of subjects in that category. *p , .05.
14% improvement. Clients’ housing problem severity scores showed 70% improvement among those who received housing services, 37% among those who did not receive housing services, and 25% among those who reported no housing needs. The positive impact with respect to vocational training services and housing services are highlighted in Figure 1. Improvements in some problem areas appeared to be associated with parallel reduction in drug use problems. For example, there was a 50% reduction in drug use severity score among those who received help with locating housing, a 23% reduction among those who did not receive help with locating housing, and a 41% reduction among those who did not declare a need for housing services. Similar improvement was observed among those who had children. For those who requested and received the service of having their children allowed at programs
TABLE 3 Multiple Regression Predicting Treatment Retention
Male Race/ethnicity Black Latino Other Age Severity of drug use Matching index Adjusted R 2
Standardized b
p
2.08
.255
2.14 2.05 2.10 .18 2.34 .16 .16
.092 .503 .171 .016 .000 .023
(Needs Matched), there was a 45% reduction in drug use severity score, while there was 20% reduction in the group that requested but did not receive the service (Needs Unmatched) and a 31% reduction in the group that did not request the service (No Needs). However, parallel improvement in a problem area and improvement in drug use severity score was not observed in problem areas other than those related to housing and child care. Retention and Posttreatment Drug Use Severity A positive correlation (r 5 .11) was found between treatment retention and improvement in drug use severity score, but it was not statistically significant (p 5 .16). Although nonsignificant, the relationship between retention and reduction in drug use was consistent with most prior studies that demonstrated positive relationships between treatment retention and favorable treatment outcome (DeLeon, 1991; Hubbard et al., 1989; Simpson, 1979, 1981). DISCUSSION The primary issue addressed in our study was whether matching client needs and program services improved client treatment outcomes, and our study results suggested that matching needs and services does matter for clients who receive requested services. The types of desired services ranged from those seven areas assessed by the ASI and housing services to those often considered
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FIGURE 1. Improvement in housing, vocation, and drug use severity: Contrasts among needs matched, unmatched, and no needs.
“wrap around” services, such as transportation and child care. Clients who received the desired services stayed in treatment significantly longer and showed more improvement in the corresponding problem area than those who did not receive the desired services. Similar patterns of improvement in drug use severity were observed in association with improvement in certain problem areas. The overall matching index also provided encouraging findings. Clients with a higher level of matching in needs and services stayed in treatment longer. Furthermore, while the benefit of matching was dramatic in many service and need areas, it should be noted that the percent of clients in the “Needs Matched” group was much smaller than that in the “Needs Unmatched” group (except for transportation). As a matter of fact, besides some general counseling, the proportion of clients who received specific services was generally low and most of their reported needs were not met in the treatment programs. This finding is similar to those reported by other studies (Etheridge, Craddock, Dunteman, Hubbard, 1995; Schottenfeld, Pascale, & Sokolowski, 1992). Given the current trend of diminished levels of funding, it is anticipated that types of services provided and planned treatment retention are likely to be further reduced in the future. The present study provides evidence that such reductions are likely to have a negative impact on client outcomes. The present study was nonexperimental. The measure of services received was limited only to the types of service asked about and gave no indication of intensity or frequency. However, the findings are consistent with other experimental and nonexperimental studies (Hoff-
man et al., 1994; McLellan, Arndt, Metzger, Woody, & O’Brien, 1993) that demonstrated that enhancing treatment services provided to clients is an important means of increasing client retention and improving treatment outcomes. The unique aspect of the present study was that client preferences and opinions were considered in measuring need for services and the potential impact of matching. Clients themselves were explicitly asked if a specific type of service was important for them to receive in their drug treatment program. The positive findings associated with client-determined needs for services suggest that clients are an important source for identifying needs and designing treatment plans and service provision. REFERENCES Anglin, M.D., & Hser, Y. (1990). Treatment of drug abuse. In M. Tonry & J.Q. Wilson (Eds.), Crime and justice: An annual review of research (Vol. 13, pp. 393–460). Chicago: University of Chicago Press. DeLeon, G. (1991). Retention in drug-free therapeutic communities. NIDA Research Monograph, 106, 218–244. Etheridge, R.M., Craddock, S.G., Dunteman, G.H., & Hubbard, R.L. (1995). Treatment services in two national studies of communitybased drug abuse treatment programs. Journal of Substance Abuse, 7, 9–26. Finney, J.W., & Moos, R.H. (1986). Matching patients with treatments: Conceptual and methodological issues. Journal of Studies on Alcohol, 47, 122–134. Hodgson, R. (1994). Treatment of alcohol problems. Addiction, 89, 1529–1534. Hoffman, J.A., Caudill, B.D., Koman, J.J., III, Luckey, J.W., Flynn, P.M., & Hubbard, R.L. (1994). Comparative cocaine abuse treatment strategies: Enhancing client retention and treatment exposure. Journal of Addictive Diseases, 13, 115–128. Hser, Y. (1995). A referral system that matches drug users to treatment
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305 McLellan, A.T., Luborsky, L., Woody, G.E., & O’Brien, C.P. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease, 168, 26–33. McLellan, A.T., Woody, G.E., Metzger, D., McKay, J., Durrell, J., Alterman, A.I., & O’Brien, C.P. (1996). Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons. Milbank Quarterly, 74, 51–85. Miller, W.R. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98, 84–107. Miller, W.R. (1989). Matching individuals with interventions. In R.K. Hester & W.R. Miller (Eds.), Pergamon General Psychology Series: Vol. 157. Handbook of alcoholism treatment approaches: Effective alternatives (pp. 261–271). Elmsford, NY: Pergamon Press, Inc. Nurco, D.N., Shaffer, J.W., Hanlon, T.E., Kinlock, T.W., Duszynski, K.R., & Stephenson, P. (1988). Relationships between client/counselor congruence and treatment outcome among narcotic addicts. Comprehensive Psychiatry, 29, 48–54. Polinsky, M.L., Hser, Y., Anglin, M.D., & Maglione, M.A. (1998). Drug-user treatment programs in a large metropolitan area. Substance Use and Misuse, 33, 1739–1765. Schottenfeld, R.S., Pascale, R., & Sokolowski, S. (1992). Matching services to needs: Vocational services for substance abusers. Journal of Substance Abuse Treatment, 9, 3–8. Simpson, D.D. (1979). The relation of time spent in drug abuse treatment to posttreatment outcome. American Journal of Psychiatry, 136, 1449–1453. Simpson, D.D. (1981). Treatment for drug abuse: Follow-up outcomes and length of time spent. Archives of General Psychiatry, 38, 875–880.